August 19,2014

Because one of our sites has decided to replace some generations-old equipment, I had the joy of going on two site visits over the past couple of weeks. Both were sponsored by BIG NAMES, and both fell rather short. Which prompts me to examine the entire concept of the site visit.

In brief, the site needs two quite different pieces of equipment, both sold by the BIG VENDORS in question. Both teams got only half of it right, one showing us the first, and one showing us the second. Both seemed to be a little oblivious to the fact that we needed one of each. My recommendation at this point is to buy one machine from one vendor and the other from the other. I doubt that will happen.

So what went wrong? I'm not totally sure, but I think it probably comes down to someone not listening. I think we made our needs pretty clear, but...

Site visits can be fun, at least they were in the old days. I've been on what might have been one of the more expensive equipment junkets in the history of imaging. We had two Elscint CT's at the time, and the company wanted us to consider their MRI's. Our trip started at Elscint HQ in Haifa, Israel, and then took us to Kiel, Germany to see the only prototypes in existence of the machines we sought. The machines were actually quite impressive. Elscint had created one of the first high-field scanners, a 2T device, as well as a dual-gradient machine. There was just one little catch. The week before we left for the trip, Elscint was SOLD! GE purchased the nuclear medicine and MRI divisions, and Picker (later Philips) snagged the CT business. So GE ate the bill for me and my partner to look at scanners that were never manufactured! We did have a good time, though.

What is the point of a site visit? To see the machine? Here's a little secret: Most every scanner is a big box with a hole in it. Some have prettier cowling than others, some have a water-chiller in the corner, which looks rather like a fridge. Some have really nice LCD displays over the gantry. Whoopie. More importantly, one gets the chance to talk to the users, technologists, physicians, whomever. Usually, the salesmen have the tact to disappear for a moment so the bad stuff can be discussed as well as the good. (Bad stuff does come out..on our Fuji PACS site visit years ago, the PACS admin said, "Fuji support isn't so good and we have to maintain the system ourselves." Which was the end of Fuji.)

Of course, the most important part is the obligatory meal at vendor expense. But the days of picking the most expensive wine on the list are gone, and frankly I never felt terribly comfortable spending the vendors' money on frivolity anyway. Not that a fancy meal or trip can or should influence my choice, but the optics are what they are.

Ultimately, I think the days of the site-visit are numbered.

My friend Mike Cannavo, once again the One and Only PACSMan, ghost-wrote this paragraph for my RSNA Christmas Carol fantasy:
“Isn’t it obvious?” (the PACSMan) asked. “Here’s the deal. No one knows where healthcare is going, so we’re all going to start enjoying Thanksgiving again for the first time in 75 years. Instead of freezing our asses off, we’ll do an interactive virtual conference with scheduled demos and everything. No muss, no fuss, and no ‘free’ meals. As a bonus, system prices will drop 30% because vendors won’t have to pay for RSNA. It’s sheer brilliance, I tell ya!"
Mike was referring to the vendor extravaganza at RSNA, but I think this applies to site-visits as well. There is simply no need to haul people across the countryside (or country, for that matter) to see the scanner. They all look pretty much the same, and decisions are not made on the basis of their appearance. (Bore size and other specs are important, but that's all in the specs.)

Conversations with the important people can be choreographed by phone with little difficulty. And images, the most important piece of my puzzle, can be sent, hopefully in a form that will easily load on the customers' PACS. (Yes, that can be a problem.)

Hey, I like a paid day off as much as anyone else, but I'm getting too old to drag my carcass around the neighborhood and indeed the country to spend 5 minutes in the presence of the Holey Box and its keepers . Let's save a few thousands (or tens of thousands) of dollars and try it my way.

I've probably just made myself a target for those who like getting wined and dined and taken to various exotic places like we just were, but time change, boys. Go spend the time with your family instead. That goes for the vendors, too.
Dalai's note: This piece is reprinted from today's American Thinker. It is one of the most eloquent, heartfelt, and most importantly, ACCURATE renditions of the Mideast situation today. It is a long essay, but well worth your time. Know the history. Know the TRUTH.

Speaking Truth to Crap

By Dan Gordon

I've been home from participating in Operation Protective Edge for about a week. I am in uniform no more, though I still wear my dog tags in solidarity with my brothers in arms, who, like all citizens of Israel, await the outcome of cease-fire talks in Cairo. Because we never wanted this war. It was forced upon us by Hamas. The current cease-fire is set to expire Monday at Midnight Israel time. Hamas has repeatedly rejected and/or violated each past cease-fire, so no one knows what will happen with this one.

I admit to being a bit cranky.

I don't think it's PTSD, though I've been to too many funerals, had a few too many close calls with rockets and mortars, had people with whom I'd celebrated the night before be killed the next day, seen chunks of the skull of a sixteen year old blown off by shrapnel from a mortar round I successfully dodged, only through luck and the grace of a loving G-d, who, I choose to believe, still has some use for me on the planet.

The song "Fire and Rain" is playing on the local oldies station and I think to myself, " Oh James, you Sweet Hippie Child, you haven't seen anything..."

You haven't been in a shelter during a rocket attack trying to comfort a little girl with nothing but the BS of an adult trying to comfort a child in a rocket attack, who knows better. You haven't seen people race for cover knowing they have only seven seconds before risking being blown apart. You haven't met people who've had to lock themselves in a so called safe room, while only a few hundred meters away a dozen terrorists, armed with anti tank missiles that could incinerate their home, machine guns, grenades, thousands of rounds of ammunition and hand cuffs, with which to take them prisoner and drag them through terrorist tunnels, into underground cells, are on the prowl, and they, this sweet family in a locked room, know that they are their targets. They will live or die in the next hour, depending upon the skill and bravery of eighteen and nineteen year old boys and girls, who are willing to lay down their lives, not to promulgate any occupation, nor subjugate another people, but to protect their homes and families, and on this particular day, some of those kids will do just that. They will lay down their lives to protect this family and others like them. The terrorists' secret "Divine Victory Plan" to kill, maim and take hostage, Israeli men women and children will be foiled and there will be new funerals of nineteen year olds who've given their lives to save the lives of that family huddled together behind a locked door in their home. And you think you've seen Fire and Rain, James?

Since I'm back I've become appalled by the lack of journalistic integrity I've seen in some coverage, and the sheer ignorance in the coverage of others.

I like listening to NPR on weekends. They have a comedy game show called "Wait, Wait Don't Tell Me." I'm driving from a friend's house and searching for it on the radio and an NPR news cast comes on. It's about Gaza, so reflexively, like all Israelis, I turn the sound up. Are we at war? Are rockets falling again? The reporter comes on. She has well modulated, upper crust British Public School pronunciation, as she describes the plight of Palestinian Fisherman in Gaza who now have a five hundred meter limit placed on their fishing activities by the Israeli Navy in the wake of the recent war. She describes it as if it is some cold hearted, at the very least, collective punishment of innocent Gazan Fisherman.

I mean how cruel can these Zionist oppressors of the downtrodden Gazan fishermen be?

We're talking fishermen here!

Peter was a Fisherman. Jesus preached on the shores of the Sea of Fishermen! Just like these poor Palestinian Fishermen whom the Israelis cruelly limit to fishing only five hundred meters from shore!


I can almost see a new site to match "Jesus at the Checkpoint," which tries to say if Jesus of Nazereth were alive today he would be a poor Palestinian, harassed by Roman-like, Jewish, Nazi soldiers at checkpoints in the West Bank. Jesus would be, were he alive today, separated from his neighbors by "The Apartheid Wall"!

Never mind that the checkpoints were a response to, and preventative measure against, the suicide bombers who claimed a thousand Israeli lives, who blew up women and children in pizza parlors and Passover Seders.

As for the so-called " Apartheid Wall," it is a security fence, only three percent of which is a thirty foot high wall. And why is there even three percent which is a thirty foot high wall? Because for years Palestinian terrorists from Kalkiliya and Tul Karem would shoot at cars on the Trans-Israel highway and kill Israelis. And by the way, since the barrier has been there, it's stopped almost a hundred percent of the suicide attacks. Period.

It's not Apartheid you bozo! It's self-preservation!

Twenty percent of Israel's population are Arabs, many of whom define themselves as Palestinian. They sit on our Supreme Court, which recently sent a former Israeli president and a former Israeli Prime Minister to Jail. They study and teach in our universities, serve in our military, are doctors and nurses in our hospitals, and enjoy the protection of the least corrupt, most liberal judiciary in the entire Middle East. Indeed no Arab country affords them the rights they have as citizens of Israel. Does that sound like Apartheid to you? I'll tell you what sounds like Apartheid. It is the fact that virtually every Palestinian leader has said that not one Jew will remain in a Palestinian state once it is created. In other words Judenrein. Jew-Free. Hitler's wet dream

But I digress.

Pardon the rant. I said I was cranky. Back to the poor Gazan fishermen who can't fish beyond a five hundred meter limit imposed by the Israeli Navy during the current war. What this Brit twit of an Oxbridge reporter fails to mention is that Hamas terrorists attempted to stage a water-borne terrorist attack on Zikkim beach near the Israeli city of Ashkelon. Happily, they were engaged and killed by some more 19-year-old Israeli kids willing to lay down their lives to protect the Israeli civilian farmers at Kibbutz Zikkim, where the terrorists were headed. That's why there's a five hundred meter restriction! Because Hamas terrorists, posing as poor Gazan fisherman, indeed, tried to carry out a terrorist attack against our civilians. Gazan fisherman are paying the price for Hamas terrorist attacks on Israeli civilians. But the Oxbridge modulated tones never mention that. They just sadly intone her name, and solemnly bear witness to yet another Israeli act of tyranny.

Gimme a break!

Do your homework you twit. Keep your prejudice, if you like, in the melodrama you wrote in your head before you ever even got there, but provide at least a little bit of context. Whattaya say?

All of which brings me to Jon Voight.

Mr. Voight recently penned an open letter to Javier Bardem and his equally talented wife, Penelope Cruz, for signing an open letter condemning Israel as a war criminal without once mentioning the name, let alone the deeds of Hamas. Mr. Voight took them to task and recounted Israel's history in a workman-like fashion, hoping to educate them, and his readers, regarding the facts leading up to the current conflict.

Mr. Voight has thus, recently been taken to task himself, by a member of Academia who has chosen to identify with the downtrodden, put-upon, maligned and much misunderstood freedom fighters of Hamas.

He has done so by taking his stand against the capitalist, pig, oppressors of the Palestinian masses, namely the dreaded Zionists.

He flaunts his academic credentials to poor Mr. Voight, a mere actor, and present the true facts and myths surrounding Israel, even going so far as to cite like-minded Jewish and Israeli academics, in order to enlighten the aforementioned, and hopelessly naive Mr. Voight. He, after all, has written and edited books specializing on (his grammar, not mine) the history and contemporary realities of Israel, Zionism and Palestine. The conclusion which the professor has drawn is that the United States and Israel are to blame "for the suffering Israel has inflicted on the Palestinian people." And to ice that academic cake, and bolster his argument to irrefutable heights, which, no mere actor could ever hope to scale, he quotes that leading expert on all things Middle Eastern, none other than John Leibowitz!

Oh...what's the matter ? You never heard of John Leibowitz?

That's because this particular proud Jewish comic, unlike guys named Seinfeld, Sandler, and Stiller, felt he couldn't make it merely on his talent. I mean, who ever heard of a Jewish Comedian? So he Anglicized himself into becoming a homey of the Oxbridge Patron Saint of Palestinian Fisherman, and thus, was born again as, Jon Stewart.

I like Jon Stewart.

I think Jon Stewart's a funny guy.

I think he's so funny, in fact, he could even have made it even if his name was Leibowitz.

But I'd no more depend on his analysis of the current conflict in the Middle East, than I would consult with Dr. Pepper about a medical condition. Dr. Pepper's a heck of a soft drink. But by Doctors, he's no doctor.

So this is not an open letter to this bozo of new left chic Academia. But it is a refutation of the same talking points raised by his fellow travelers seeking to delegitimize Israel's very right to exist as the sovereign nation state of the Jewish people. First of all, what you have to understand is, the very notion of a sovereign Jewish state, within any borders, is anathema to this crowd. They live in an enlightened, post-nationalistic mindset, where the only people in the Middle East entitled to be nationalists, in fact, are those who wish to establish, not a nation, but a Caliphate.

Regarding the birth of Israel in 1948, Mr. Voight rightly cites it having come about as a result of Israel's acceptance of the 1947 UN plan to partition Palestine into two states, one Jewish and one Arab. The Arab League and the Palestinians, represented by their revered leader Haj Amin Al Husseini, rejected the partition plan and the establishment of any Jewish State within any borders, and as Mr. Voight pointed out, Israel was subsequently "attacked by five surrounding Arab countries committed to driving them into the sea,"

The professor counters that poor Mr. Voight has been taken in by a Zionist myth. "This is a distortion of the actual history, which saw Zionism arrive on the soil of a Palestine that was already in the midst of its own modernization." The Zionists, he states, deployed "the conquest of labor" and then "the conquest of the land" to increasingly powerful effect once the British conquered Palestine in 1917"

I have heard this particular talking point from various radical left professors who have almost inexplicably cast their lot with misogynistic, gay hating, democracy hating, female genital mutilating, child bride abusing, murderous thug terrorists! I am a child of the left. I attended my first civil rights march at the age of ten. My first presidential campaign was for Jack Kennedy and my second was for Bobby. You can still find my blog supporting Barack Obama's first election on the Huffington Post. To have people who proclaim that they are for the universal rights of man, for equality of the sexes, for peace and justice, side with Hamas terrorists and claim their superiority over a Western democracy like Israel, makes me want to puke at the very perversity of the notion.

As the saying goes, everyone is entitled to his own opinion, but not his own facts.

So what exactly was this "soil of a Palestine…already in the midst of its own modernization" when Zionisim arrived? Well let's quote someone who was there, on that very soil a mere fifteen years before Zionism arrived. Mark Twain toured the Holy Land in 1867. Zionism arrived in 1882. What was the soil that Twain, no slouch of a social observer he, saw and described in his book, Innocents Abroad?

In describing the Valley of Jezreel, he states, "There is not a solitary village throughout it's whole extent -- not thirty miles in either direction. There are two or three clusters of Bedouin tents, but not a single permanent habitation. One may ride ten miles, hereabouts, and not see ten human beings."

I mention the Valley of Jezreel in particular, because that's where I was partially raised, went to high school, from whence I went into the army, where I was married, where I taught high school and farmed and wrote and where my first born son, of blessed memory, was born. I know the Valley of Jezreel as well as I know any place on earth. It is the breadbasket of Israel, home to some of the most successful and stunning agriculture on earth. It is alive and bustling with farming villages, schools, colleges, high tech industry, and agriculture R&D that is the envy of the world. It abounds in forests, each tree of which was bought and paid for by Jews around the world, as was the land itself, which was stolen from not one Palestinian, because it was worthless and desolate and sold at inflated prices to the Jews who were so insane they paid handsomely for barren soil, which they turned into paradise through..."the conquest of Labor"!

There was a time when leftists actually praised labor! But this was Jewish labor. Jews working with their hands in backbreaking labor and I am old enough to have actually known that founding generation, and their love of that land which was as bare and desolate as when Twain first visited. They made it bloom through "the conquest of labor." Unlike these pious Academic poseurs, they engaged in backbreaking work to plant forests and create thriving agricultural villages. They were idealistic young students who displaced no one in their "conquest of the land," which any enlightened progressive today should realize was carried out by the oldest and most effective ecological society in the world, The Jewish National Fund, which saw to it that Israel was the only nation on earth to enter the twenty-first century with more trees than it had in the century before. And you creeps dare to distort that into some kind of crime!

Here's is Twain's description of the Galilee before the arrival of Zionism: "These un peopled deserts, these rusty mounds of bareness, that never, never, never do shake the glare from their harsh outlines...; that melancholy ruin of Capernaum, this stupid village of Tiberias, slumbering under six funereal palms...A desolation here that not even imagination can grace with the pomp of life and action." That was the Galilee then. Visit it today and be amazed at "the pomp of life and action" all of which was brought in through the conquest of labor of the Zionist Jews literally reclaiming the land from the desert it had become.

Regarding Israel's acceptance of the 1947 UN partition plan and the Arab/ Palestinian rejection of same, the professor states, "The Zionist leadership ‘accepted’ the terms of the 1947 Partition Plan. In reality, they had little intention of actually fulfilling them, and over the next year, through inter communal conflict and then all out war, three quarters of a million Palestinians were permanently forced from their homes,"

Again the intellectual dishonesty by a supposed academic is simply staggering.

Here are the facts:

There never was a state of Palestine. Never. Not once in history. Prior to WW I, what is called Palestine, which comprised Israel of today, Gaza, Judea and Samaria and all of Jordan, comprised a sleepy backwater province of the Ottoman Empire. The Ottomans sided with the Germans, In WW I, and for those who don't remember, they lost the war. The League of Nations, forerunner of the UN, broke up the old Ottoman empire and at the San Remo Conference of 1921, passed a resolution "In favor of the establishment of a national home for the Jewish people…." The resolution went on to state. "Whereas recognition has thereby been given to the historical connection of the Jewish people with Palestine, and to the grounds for reconstituting their national home in that country..." the resolution went on to appoint Britain to have a mandate over Palestine, which "shall be responsible for placing the country under such political, administrative and economic conditions as will secure the establishment of the Jewish national home.... The Mandatory shall be responsible for seeing that no Palestine territory shall be ceded or leased to, or in any way placed under the control and Government of any foreign power."

That last point is particularly important because Britain, in contravention of its duties as a mandatory power, lopped off the bulk of the territory and created out of whole cloth, with 70% of what was to have been the Jewish National home, a Palestinian Arab country, and called it Transjordan, which today is known simply as Jordan. But under international law it was to have been part of "The Jewish National Home"!

In 1936, following Arab massacres of ancient Jewish communities in Hebron and Safed, the British appointed the Peel Commission, which offered to partition the 30% of remaining land into two states; one Jewish and one Arab. Two thirds of the state would have gone to the Palestinian Arabs and one third to the Jews. The Palestinian Jews accepted the plan and the Arabs, who called themselves Arabs, and not Palestinians, again led by Haj Amin Al Husseini, rejected it. The Jews accepted this tiny enclave for one reason. It was 1937 and they knew what was about to happen to the Jews of Germany and Europe. When Hitler wanted to rid Europe of its Jews, not one country in the world would take them in and they literally went up in the smoke and ash of the crematoria of Hitler's death camps. Had Israel been born, even in it's Lilliputian form in 1937, six million Jews and all their descendants would have been alive today.

But, say the esteemed academic supporters and enablers of Hamas and their ilk, that just proves their point. The Palestinians had no part in the Holocaust, and yet they were made to pay the price by accepting into their midst the European survivors of European mass murder, that had nothing to do with them.

Really? Really?

Here are the facts, yet again, troublesome as I know they are.

When Britain went to war against Nazi Germany, the Jews of Palestine rushed to enlist in the British Army and eventually formed the Jewish Brigade which, together with its predecessor Jewish Palestinian units, fought valiantly in North Africa and in Europe, and played their part in the defeat of Nazi Germany.

And where was Haj Amin Al Husseini, the revered leader, indeed founder, (and uncle of Yasser Arafat) of the Palestinian Arab National Movement?

He was Hitler's poodle in Berlin.

So don't peddle this revisionist crap that the Palestinians had no part in the extermination of European Jewry and Nazi war crimes, because their leader Haj Amin Al Husseini sure as hell did!

He met with Mussolini and Himmler and Eichman and Hitler himself.

He joined the Nazi war effort by helping recruit Muslim units under German SS command that were responsible for mass murders in Croatia and Hungary.

Indeed Yugoslavia sought to have Haj Amin Al Husseini indicted for war crimes for his role in recruiting 20,000 Muslims, who participated in mass murders of Jews and others in Central Europe. In 1944, on Radio Berlin, Haj Amin Al Husseini, the father of the Palestinian National movement said, "Arabs, rise as one man and fight for your sacred rights. Kill the Jews wherever you find them! This pleases God, history and religion!"

He issued a statement saying, “Those lands suffering under the British and Bolshevik yoke impatiently await the moment when the Axis powers will emerge victorious. We must dedicate ourselves to unceasing struggle against Britain, that dungeon of peoples."

That's what the leader of the Palestinian Arabs was doing when my foster father and the other members of His Majesty's Jewish Brigade were fighting and defeating the Nazis in Europe.

As to the 1948 War of Liberation, far from being invaded by five surrounding Arab countries determined to make the Mediterranean red with the blood of the Jews, the professor claims that the Arab forces were minimal and badly trained and equipped, and were sent to prevent themselves from looking like collaborators, and to prevent their rival, Haj Amin Al Husseini, "from establishing a state".

Wait a second! Did this Bozo just say the Arab armies invaded the nascent state of Israel to prevent the establishment of a Palestinian state?

You bet. That's what he said. The Arabs, not the Israelis, prevented the establishment of a Palestinian state.

Egypt conquered Gaza and annexed it, without giving its inhabitants benefit of Egyptian citizenship.

Jordan annexed the West Bank and all the Palestinians there became Jordanian citizens. And by the way, no one at the time suggested ever turning those lands into a Palestinian state. At those times when they referred to occupied territory, they were talking about, and Hamas still talks about, Tel Aviv!

As to how badly trained and equipped the poor five invading Arab armies less an expert than General George Marshall, Chairman of the Joint Chiefs during WWII and President Truman's most trusted advisor, said that if the Jews declared independence they would be wiped out within two weeks. And he was right to think so. The "poorly equipped" Egyptians had a 10,000 man armored column less than an hour and a half drive from Tel Aviv. There was not one Israeli soldier between them and Israel's largest city. On the next morning they would drive into Tel Aviv and the two thousand year old dream of a Jewish state would be over. And what did those colonialist, imperialist, pig, Zionists have, with which to fight that 10,000 man armored column?

They had four Czech-built ME 109 fighter planes which had been smuggled into Israel in pieces, re assembled in hangars, had never been test flown, had never had their weapons test fired, possessed neither avionics nor radios so the pilots had to communicate with each other with hand signals, and for aeronautical charts had Palestine Auto Club road maps and boy scout compasses glued to the dashboards.

I know because I am privileged to know the man who led the attack of those four ME109s. He refers to me as his younger brother and it is one of the greatest honors of my life to be counted as his friend. His name is Lou Lenart. He and his three other pilots were told that the fate of the Jewish state rested on their shoulders. They were to take off and stop that armored column. If they failed, Israel was dead. Lou pulled out onto the tarmac, looked behind him at the three other planes and saw the entire Israeli Air Force.

But they did it.

They stopped the Egyptian column dead in its tracks and bought Israel the time it needed to survive.

Of the four pilots, they suffered fifty percent casualties on their first mission.

In Israel's war of Liberation in 1948 it lost one percent of its population killed. That would be the equivalent of America losing three million killed in one year. America has lost a little over one percent of that number in ten years of combat and they say America is “war weary.” What do you think Israel was?

Finally, these mouthpieces for terrorist thugs, wrapping themselves in the robes of Academia, claim that it was Israel that started this current war, and not Hamas.

But that's quite simply a lie.

And we know it's a lie because Hamas did not start digging those thirty two terrorist attack tunnels when Israel started it's aerial campaign against them. Those tunnels were an offensive weapon which was to have handed Hamas their "shock and awe," their 911 moment that would have brought Israel to its knees. They began digging those tunnels five years ago with the cement and steel they stole from their own people, with the cement and steel that was meant to rebuild Gaza, to build schools and hospitals and prenatal clinics. And instead they used it to build terrorist attack tunnels under Israel's internationally recognized 1967 border, aimed exclusively against Israeli civilians, whom they would have murdered, maimed and taken hostage by the dozens. This was their offense, planned and executed at the time of their choosing. But following their doctrine of carrying out terrorist attacks and then claiming the mantle of victimhood, with so called academics as their mouth pieces and enablers, they had to make it look like it was a response to Israeli aggression. So they publicly ordered the kidnap murder of three Israeli schoolboys on their way home from school.

And Israel didn't fire a shot into Gaza. They just engaged in a campaign to round up Hamas terrorists in Judea and Samaria, where the boys had been kidnapped and killed.

Then Hamas started firing rockets at Israel and Israel said repeatedly, “Calm will be answered with Calm."

They must have thought to themselves, " What's a guy got to do to start a war with these Jews?"

Then they upped their rocket attacks to a hundred a day and Israel still said "calm will be answered with calm" while they began their aerial campaign.

Finally a ceasefire was to have taken affect.

Israel accepted it.

Hamas rejected it by launching a major rocket barrage, and then the first of six terrorist tunnel attacks, and that's when Israel had no choice but to respond with a ground invasion to take out what was indeed an existential threat.

Of the 1800 Palestinians killed in this conflict, 1600 of them would be alive today if Hamas had only accepted the cease-fire Israel accepted immediately and unconditionally.

But as I said, they weren't interested in a cease-fire.

This was their war and they thought they could win it.

And don't you buy the crap so-called academics are peddling, that Hamas was the duly democratically elected government of Gaza. Hamas took power, not in an election, but in a bloody coup, machine gunning their fellow Palestinians, blindfolding, binding and throwing them off of multi story buildings. They have terrorized their own people, not only Israel. Their people, indeed, live under the yoke of occupation, but not by Israel, by Hamas.

And as for the apologists and enablers of Hamas, who contribute to the misery of Palestinians and Israelis alike, while sitting in their club chairs in the faculty lounge, may I suggest that from now on they speak only through the orifice which Mr. Voight has so eloquently enlarged for them, since what they are peddling is pure, unadulterated crap.

August 18,2014


A typical day at work...from I Love Lucy, first aired September 15, 1952

There are days when the grind feels a lot like Lucy's candy factory as seen in the clip above. But the beat goes on, the images keep coming, and they have to be read. As one of my professors used to say, "Miss 'em slow, or miss 'em fast, boys!" Of course, that was a joke. Of course it was. Definitely.

You probably know the difference between sensitivity and specificity. In essence, sensitivity is the percentage of the time you find something that is actually present. Specificity is the percentage of the time you don't find something when nothing is there. In other words, were I 100% sensitive, I would find every cancer that comes through on the PACS worklist. Were I 100% specific, everyone I declare negative will truly be without disease. Put in tabular form (courtesy of Penn State's online Stat course):

I want all my positives and negatives to be true, with no false positives (saying there is disease when there isn't) or false negatives (saying there is no disease when there is.)

There is a whole science surrounding this stuff. Everyone, and particularly every radiologist, has a different set of sensitivities and specificities, and this is all wrapped up in a concept called Receiver-Operating Characteristics, or ROC. From MediCalc:

In a Receiver Operating Characteristic (ROC) curve the true positive rate (Sensitivity) is plotted in function of the false positive rate (100-Specificity) for different cut-off points. Each point on the ROC curve represents a sensitivity/specificity pair corresponding to a particular decision threshold. A test with perfect discrimination (no overlap in the two distributions) has a ROC curve that passes through the upper left corner (100% sensitivity, 100% specificity). Therefore the closer the ROC curve is to the upper left corner, the higher the overall accuracy of the test (Zweig & Campbell, 1993).
Got it? Just remember that everybody's ROC is going to be different, with different blends of sensitivity and specificity.

Fellow radiologist and wannabe writer Saurabh Jha, M.D., takes the concept one step further with his "fictional" colleagues, Drs. Singh and Jha. I'm guessing the second isn't fictional at all, and I'm sure he based the first on someone he knows.  Anyway, Dr. Jha wrote this piece published in the Healthcare Blog, and republished by KevinMD, and also cited by several radiologist friends of mine.

Who Is the Better Radiologist?

There’s a lot of talk about quality metrics, pay for performance, value-based care and penalties for poor outcomes.

In this regard, it’s useful to ask a basic question. What is quality? Or an even simpler question, who is the better physician?

Let’s consider two fictional radiologists: Dr. Singh and Dr. Jha.

Dr. Singh is a fast reader. Her turn-around time for reports averages 15 minutes. Her reports are brief with a paucity of differential diagnoses. The language in her reports is decisive and her reports contain very few disclaimers. She has a high specificity meaning that when she flags pathology it is very likely to be present.

The problem is her sensitivity. She is known to miss subtle features of pathology.

There’s another problem. Sometimes when reading her reports one isn’t reassured that she has looked at every organ. For example, her report of a CAT scan of the abdomen once stated that “there is no appendicitis. Normal CT.” The referring physician called her wondering if she had looked at the pancreas, since he was really worried about pancreatitis not appendicitis. Dr. Singh had, but had not bothered to enlist all normal organs in the report.

Dr. Jha is not as fast a reader as Dr. Singh. His turn-around time for reports averages 45 minutes. His reports are long and verbose. He meticulously lists all organs. For example, when reporting a CAT of the abdomen of a male, he routinely mentions that “there is no gross abnormalities in the seminal vesicles and prostate,” regardless of whether pathology is suspected or absence of pathology in those organs is of clinical relevance.

He presents long list of possibilities, explaining why he thinks a diagnosis is or is not. He rarely comes down on a specific diagnosis.

Dr. Jha almost never misses pathology. He picks up tiny lung cancers, subtle thyroid cancers and tiny bleeds in the brain. He has a very high sensitivity. This means that when he calls a study normal, and he very rarely does, you can be certain that the study is normal.

The problem with Dr. Jha is specificity. He often raises false alarms such as “questionable pneumonia,” “possible early appendicitis” and “subtle high density in the brain, small punctate hemorrhage not entirely excluded.”

In fact, his colleagues have jokingly named a scan that he recommends as “The Jha Scan Redemption.” These almost always turn out to be normal.

Which radiologist is of higher quality, Dr. Singh or Dr. Jha?

If you were a patient who would you prefer read your scan, the under calling, decisive Dr. Singh or the over calling, painfully cautious Dr. Jha?

If you were a referring physician which report would you value more, the brief report with decisive language and a paucity of differential diagnoses or the lengthy verbose report with long lists on the differential?

If you were the payer which radiologist would you wish the hospital employed, the one who recommended fewer studies or the one who recommended more studies?

If you were a hospital administrator which radiologist would you award a higher bonus, the fast reading Singh or the slow reading Jha? This is not a slam dunk answer because the slow-reading over caller generates more billable studies.

If you were hospital’s Quality and Safety officer or from Risk Management, who would you lose more sleep over, Dr. Singh’s occasional false negatives or Dr. Jha’s frequent false positives? Note, it takes far fewer false negatives to trigger a lawsuit than false positives.

I suppose you would like hard numbers to make an “informed” decision. Let me throw this one to you.

For every 10, 000 chest x-rays Dr. Singh reads, she misses one lung cancer. Dr. Jha does not miss a single lung cancer, but he recommends 200 CAT scans of the chest for “questionable nodule” per 10, 000 chest x-rays. That is 200 more than Dr. Singh. And 199/ 200 of these scans are normal.

I can hear the siren song of an objection. Why can’t a physician have the sensitivity of Dr. Jha and the specificity of Dr. Singh? The caution of Jha and the speed of Singh? The decisiveness of Singh and the comprehensiveness of Jha?

You think I’m committing a bifurcation fallacy by enforcing a false dichotomy. Can’t we have our specificity and eat it?

Sadly, I’m not. It is a known fact of signal theory that no matter how good one is, there is a trade-off between sensitivity and specificity. Meaning if you want fewer false negatives, e.g. fewer missed cancers on chest X-ray, there will be more false positives, i.e. negative CAT scans for questioned findings on chest X-ray.

Trade-off is a fact of life. Yes, I know it’s very un-American to acknowledge trade-offs. And I respect the sentiment. The country did, after all, send many men to the moon.

Nevertheless, whether we like it or not trade-offs exist. And no more so than in the components that make up the amorphous terms “quality” and “value.”

Missing cancer on a chest x-ray is poor quality (missed diagnosis). Over calling a cancer on a chest x-ray which turns out to be nothing is poor quality (waste). But now you must decide which is poorer. Missed diagnosis or waste? And by how much is one poorer than the other.

That’s a trade-off. Because if you want to approach zero misses there will be more waste. And if we don’t put our cards on the table, “quality” and “value” will just be meaningless magic talk. There, I just gave Hollywood an idea for the next Shrek, in which he breaks the iron triangle of quality, access and costs and rescues US healthcare.

If I had a missed cancer on a chest x-ray I would have wanted Dr. Jha to have read my chest x-ray. If I had no cancer then I would have wanted Dr. Singh to have read my chest x-ray. Notice the conditional tense. Conditional on knowing the outcome.

In hindsight, we all know what we want. Hindsight is just useless mental posturing. The tough proposition is putting your money where your mouth is before the event. Before you know what will happen.

This is the ex-ante ex-post dilemma. In case you want a clever term for what is patently common sense.

Dr. Singh is admired until she misses a subtle cancer on a chest x-ray. Then Risk Management is all over her case wondering why? How? What systems must we change? What guidelines must we incorporate?

Really? Must you ask?

Dr. Jha, on the other hand, is insidiously despised and ridiculed by everyone. All who remain unaware that he is merely a product of the zero risk culture in the bosom of which all secretly wish to hide.

The trouble with quality is not just that it is nebulous in definition and protean in scope. It can mean whatever you want it to mean on a Friday. It is that it comprises elements that are inherently contradictory.

Society, whatever that means these days, must decide what it values, what it values more and how much of what it values less is it willing to forfeit to attain what it values more.

Before you start paying physicians for performance and docking them for quality can we be precise about what these terms mean, please?

Thank you.
So what is quality? I guess getting it right every time would be a good start. But that really isn't in the realm of human performance. No one has a vertical ROC curve. If you read enough X-rays and scans, you will miss something. The old saying goes that the only way not to miss anything is not to read anything. That's not very practical.

Our fictional Dr. Singh misses one lung lesion for every 10,000 studies read. Let's say that she reads 200 studies per day; she will miss something every 50 days, every two months or so. Is this acceptable? Frankly, it is fantastic. A rate within acceptable human parameters would be more like missing something on one of every one hundred exams, something like once or twice a day. Is this acceptable? Not, I suppose, if the lesion is in your chest, or your relative's. But it is a completely reasonable number for a flawed human being. Average radiologist miss rates have been quoted at anything from .1% to 30%. An ACR presentation based in part on Dr. David Yousem's materials reveal the following uncomfortable facts:
  • Radiologists error rate reported at 30%
  • >70% perceptual
    • abnormality is not perceived, i.e. “missed”
  • <30% cognitive
    • Abnormality is perceived but misinterpreted
  • Error does not equal negligence
    • Negligence occurs when the degree of error exceeds an accepted standard
  • Missed diagnoses are the major reason radiologists are sued 
    • Most commonly missed: 
      • Cancers (breast and lung are the largest percentacge) 
      • Spine fractures 
  • Retrospective error/miss rate averages 30% (i.e. hindsight is 20-20) 
  • “Real-time” error rate in daily practice averages 3-5%
So back to sensitivity and specificity. Is it possible to be 100% sensitive and find every single lesion, never having a false negative? Yes, if you read VERY slowly and call everything positive, then yes, you will pick up every cancer, but in the process, you will prompt a lot of unnecessary negative scans (and a lot of anxiety) for all the little dots that weren't really cancers after all. This is the fictional Dr. Jha, and no one appreciates him, it seems. Can you be 100% specific, never having a false positive, and never send anyone on to an unneeded followup scan or biopsy? Sure, and then you get sued when you do miss something. And you will. I've heard it said that sometimes the lesion and the radiologist simply never meet. True enough.

The bottom line is that human beings (and their ROC curves) are anything but perfect. We can try to seek perfection by applying quality metrics and such, but in the end, what do we achieve? Possibly an outlier will come to light, someone whose miss rate is well beyond his or her colleagues, or perhaps well below the rest for that matter. So in the end, this implied rating process accomplishes nothing more than the perpetuation of the fiction of our perfection. Which raises impossible expectations in our patients, and sets the trial lawyers to licking their collective chops. After all, how can we possibly tolerate anything less than perfection? Because perfection doesn't exist.

I've told you the story of Mar-Mar, my Mother-In-Law, and her untimely passing, which was assisted by a radiological miss. My musings at the time are apropos for this discussion:
I've got enough friends who happen to be litigators to know that two things drive a malpractice suit: anger and greed/envy, and they go hand-in-hand. (And as an aside, the majority of cases appear to reach the attention of a lawyer because ANOTHER DOCTOR told the patient that something wasn't done as well as HE would have done it.) As with the young lady driving the beat-up car, an accident or even an incident that approaches such is enough to promote rage in some of us, perhaps even most of us. It doesn't matter that the act was unintentional. I did not set out yesterday to trash some kid's little red jalopy. I think it's also reasonable to say that no physician decides some morning to cause harm to his patient. A missed finding, like a parking-lot collision, is an accident. It is not meant to happen, and everyone would prefer that it doesn't. This is where greed and envy can augment the madness of rage. The young lady above, at some level, realized that my truck was likely worth 8-10 times what her beater might bring, and no doubt this got her all the more riled. Why should that doofus have a nice car? Who gave him the right to almost plow into me? He must think he owns the road, having an expensive car like that. I'll show him!

In the case of a miss or other adventure in medical errors, I think the same thing applies, although certainly with a little more justification. There is clearly a relationship between doctor and patient. If something goes wrong, the patient feels betrayed And the patient gets angry. Given the perception of docs as wealthy, the next step in the mental equation may become: he hurt me (or could have hurt me) and he's going to pay! He can afford it!

While a financial award could put a car back together again, it may not be able to fix what was broken by the medical error. Somewhere along the way, our society has decided that money can compensate for the damage, and maybe that is true. However, juries of our "peers" are wont to award huge sums as punitive measure to "punish" the "bad" doctor. And let us not forget the fact that the litigator might receive 30-50% of the proceeds.

This is wrong. The whole scenario is horrible, and accomplishes nothing but padding the pockets of the litigating AND the defending lawyers. It leads to millions and billions of dollars spent for "cover your ass" procedures and tests. And it's all predicated on the anger over an accident and the thought that there might be a gold-mine to be had having won the malpractice lottery. This must stop.

I want this to be Mar-Mar's legacy: we must forgive those who make honest mistakes. We need to remove anger, greed and envy (and lawyers) from the equation, and somehow set up some entity, some body or board, that would determine actual damages and arrange for those to be made as whole as possible, but without multi-million dollar punitive, redistributive, awards. I know this is next to impossible, as there is way too much money to be made by trying "rich" doctors in front of a jury of their "peers" who would love nothing more than to sock it to them. But it is the right thing, and all but those who profit from the malpractice industry, not just the lawyers, but the plaintiff whores who sell their testimony, know that I'm spot on. Mar-Mar would approve.
Hopefully the above discussion of sensitivity and specificity brings this all full-circle. You can see the pressures under which we operate. We are to produce the work with decisive reports one after the other after the other, functioning as Dr. Singh, but we are never to miss anything, wearing the Dr. Jha hat. Why not just do both? Because we are human and humans can't do that.

No doubt Elliot Siegel will eventually teach Watson the Computer to read imaging studies, and then we will achieve perfection. Well, maybe not. But I'd like to see the litigators sue IBM instead of us.

August 26,2014


It is apparent as we move toward value-based care and payments, that health care is dependent on so much more than what we would consider care. It’s not all up to the provider nor up to the individual patient, there’s a wide network of costs and influences from genetics to nutrition.

As we move toward digital health and digital payments, the relationships between spending, environment, and other health determinants are becoming clearer, affecting the choices we make at any moment. Behavioral choices are often driven by the social determinants of health, the cultural and economic contexts (including geography) of our day-to-day decisions.

Many things, of course, influence health and outcomes and our need for care, including, genetics, behavioral choices (smoking, drugs, alcohol, unprotected sex, obesity, preventative care, exercise, taking prescribed medications, sugar intake and nutrition), access to care, capabilities to care for oneself and many other risks.

While we tend to think in terms of science and individuals controlling outcomes, that’s at the very least a bit of hubris on the part of science. Zip codes were recently declared better at predicting outcomes than genetic codes (hat tip to Cyndy Nayer).

And these social influences are becoming better understood, because we are getting better at measuring them, with access to better data, as a byproduct of ubiquitous connectivity (although extent of connectivity is often correlated with zip code as well). We often assume that it’s all up to the individual, but most of what we do is a combination of many things including marketing, education, costs, and culture. As we spend more time online, those influences become both greater and more measurable. Tremendous value will be seen once we understand these decisions and why people make them, including social, economic and geographic influences in the context of vast networks of influences.

The impact numbers of personal choice and behavior related to health and health care spending, when you dig in, are pretty staggering, and perhaps, devastating for our financial outlook.

According to Simons Chase at, via Forbes’ Dan Munro last year:

“Consumption of junk food (for example a Twinkie or a sugary drink) is akin to a financial exchange where short-term gains are privatized and long-term costs are socialized in the form of horrific health outcomes. The metabolic donkeys – consumers – pay relatively little money and turn a blind eye to the health consequences of their food choices – instead hoisting the fantastic profits of companies like Monster and opting for a shortened, diseased life.”

Read 2 Perspectives On Food Innovation: Sodastream vs. Monster Beverage

In the Forbes article, Munro estimates that sugar may be costing the U.S. healthcare system $1 trillion. That’s 25% of healthcare’s overall $4 trillion. Estimates are that Americans eat 70 lbs of sugar a year. Even at a rather high price of $1 a pound (commodity prices are around 15 cents per pound), that’s only about $25 billion that we spend on sugar as a country for the ingredient itself (certainly we pay much more for it when it comes in a soda or Monster beverage, or myriad of other products). So the costs of sugar to the healthcare system are on the order of 40 times higher than the price of sugar itself. Sugar, or a cigarette, is very small down payment on future health costs.

Prices and financial incentives are too often left out of the equation because we haven’t found the right mix. Offering salads at McDonald’s might not work, we don’t go to McDonald’s for salads, wrong context. Low-income women, on the other hand, might be incentivized to buy and eat vegetables, and at least in limited contexts, we do see that vouchers like this can work.

Carolyn Dimitri, an applied economist at New York University, tested whether farmer’s markets vouchers would not only encourage low-income women to buy and eat more vegetables using vouchers and measuring with surveys. They found that vouchers not only encouraged the purchasing, but also the consumption of more vegetables.

According to Pacific Standard’s write-up of the article, “..this suggests that disadvantaged families may eat fewer vegetables not because of preferences or education but because of access…(and possibly) economic scarcity and its psychological effects.”

To truly understand the health system, not just the healthcare system, we’ll need to understand decisions and incentives around food. Patient engagement has direct effects on health outcomes and health spending, as has been shown many times. How closely tied is nutrition to outcomes? Certainly it’s more long-term, but we need to understand correlations and causations much sooner.

Could providers or payers benefit by providing nutritional vouchers? Is there an app or technological solution that works for reducing sugar intake?

This is one area of mobile health and app development we hear little about, despite the fact that diabetes, prediabetes, and metabolic syndrome affect more than 40% of Americans, or over 100 million people. These are Americans that will have long-term health consequences and costs.

Why aren’t we doing more to help? Is it just too hard? Is our sugar addiction just too strong? What will Apple do now that they are including Healthkit in IOS8? What can Stikk do to improve on sugar intake?

This may be one of the most difficult, but also one of the most valuable, quests in healthcare.

Who else stands to benefit from reducing the $1 trillion in sugar-related health spending? How quickly can nutritions steer some of that money, much larger than that spent on sugar, toward better health and better nutritional decisions?

Moving just a little bit of the money we spend on sugar and on sugar-related diseases will pay enormous dividends in quality of life and cost of care. At VivaPhi, we’re rolling with the Center of Health Engagement, driving new incentive programs to drive better engagement and better health. Have an idea for how to create these kinds of incentives for healthier choices? We want to hear them.

Categories: News and Views , All

August 21,2014

Global Center for Health Innovation Cleveland

Global Center for Health Innovation in Cleveland

Global Center for Health Innovation in Cleveland

The Global Center for Health Innovation opened for business last October in Cleveland, Ohio, but will officially open to the general public this October. The futuristic glass structure, designed by LMN Architects of Seattle, comprises four floors and 235,000 square feet of space. The Global Center is adjacent to Cleveland’s new underground Convention Center, also designed by LMN. Jointly, they hope to attract more healthcare-themed conferences and exhibits to Cleveland.

A Technology Showcase for All

John Paganini HIMSS

John Paganini of the HIMSS Innovation Center

HIMSS Innovation Center

HIMSS is one of the anchor tenants at the Global Center occupying the entire fourth floor. The HIMSS Innovation Center features a Technology Showcase, Simulation Center, and conference rooms. HIMSS now has a year-round exhibition space to complement its Annual Conference & Exhibition, which is the industry’s leading conference for healthcare professionals.

“This is a very interesting place, not for healthcare professionals only, but also for the general public,” according to John Paganini, Senior Manager of Interoperability Initiatives at the HIMSS Innovation Center. The aim is to drive interaction between health IT companies, healthcare professionals, and consumers.

I saw this mix in action while visiting the HIMSS Innovation Center and watching Apple conduct an educational event on replacing computers with iPads. The event attracted Apple’s new partner IBM, MobileIron Enterprise Mobility Management, app developers like HIPAAchat, physicians like Dr. Mark Aeder of the Case Western Reserve School of Medicine, and members from the social media team of the Cleveland Cavaliers.

To find a cultural “fit” for a place requires a creative process of active dialogue between our clients, colleagues and stakeholders. We have found our projects increase in richness and meaning when the design process actively engages a broad diversity of participants. – LMN Architects

“The entire building was designed to be interactive and self-guided,” says Paganini, “Touch screen monitors allow you to see all the different vendors who have interesting healthcare IT products and services out on the Technology Showcase floor. ”

GE Healthcare at HIMSS Innovation Center

Collaborative Testing for Interoperability

HIMSS is still building onto what is already an impressive list of collaborators who are interested in collaborative testing and how interoperable systems can improve quality of care for patients and communities. Paganini revealed that the HIT industry’s largest interoperability testing event, the IHE NA Connectathon, will be held at the Global Center for Health Innovation in January, 2015. More than 550 systems engineers gather annually at the Connectathon to run thousands of real-time tests and verify their systems.

use case vendors

Also on the schedule of events is the Cleveland Clinic Medical Innovations Summit taking place October 27 through 29, 2014, that will feature an Innovation Basecamp and the Top Ten Medical Innovations for 2015.

Four Floors, Four Themes

Intelligent flooring from Forbo Flooring Systems talks to caregivers and patients. For example, the flooring can alert a nurse she did not wash her hands as required.

Intelligent flooring from Forbo Flooring Systems talks to caregivers and patients. For example, the flooring can alert a nurse she did not wash her hands upon entering the room.

In addition to HIMSS’ innovation and interoperability on the fourth floor, each floor at the Global Center for Health Innovation has a theme. The first level ,”Health and Home”, offers a peek into the future with a 2,000 square foot State-of-the-Art Home. It features a living room, kitchen, bedroom, and bathroom, each designed to show how people with disabilities or health challenges can thrive through innovative healthcare technologies.

Four Northeast Ohio hospital systems are part of the Welcome Center on the first floor including the Cleveland Clinic, University Hospitals, MetroHealth System, and St. Vincent’s Sisters of Charity.

“Clinical Spaces” on the third floor is dedicated to the clinical experience, and the second floor, themed “People, Patients and Caregivers”, is dedicated to patient care including GE Healthcare, Cardinal Health, MetroHealth, Cleveland Clinic, STERIS, and BioEnterprise–Team NEO.

Biomedical Innovation and Startups

BioEnterprise–Team NEO markets Northeast Ohio’s biomedical community to the world. Over a billion dollars has been invested in 200 startup companies in the area with 41 exits since 2002. Cleveland Clinic, University Hospitals, Summa Health System, and Case Western Reserve University collectively conduct over $700 million in annual research.

Alego Health

Making Healthcare Cool

Hopefully, in the future, people will say, ‘I’ve got to go to Cleveland to see the Rock and Roll Hall of Fame, and the Global Center for Health Innovation.’ – John Paganini

All photos by Angela @healthiscool.

Categories: News and Views , All

August 20,2014

Image: CC BY 2.0 Robert Scoble

Image: CC BY 2.0 Robert Scoble

The first time I saw someone wearing Google Glass was at HIMSS14 in Orlando. My initial reaction: that guy looks like a geek. Not that I have anything against the geek look but I couldn’t imagine myself ever wearing Glass goggles while walking about in public. I’ve progressed a bit and no longer giggle when I see someone wearing a pair, yet I wasn’t impressed by the Glass-wearing guy (definitely a Glasshole) that I recently noticed driving in a car next to me.

On the other hand, plenty of folks in the health IT world were quite impressed with Dr. Rafael Grossmann, the first physician to record a surgery wearing Google Glass. Since that landmark event about a year ago, a small number of companies have popped up offering healthcare solutions that leverage Google Glass. It’s perhaps too early to tell which ones will still be around next year but here’s a short list (in alpha-order) of some that are making in-roads:

APX Labs – APX has built a robust, horizontal data-integration platform optimized for smart glasses. They promote their solution for a variety of industries in addition to healthcare, but the clinical applications focus on telemedicine, first responders, nurse and clinical EMR interfaces, vitals monitoring, administrative visibility, and medical education. From what I can tell, they either don’t have any healthcare customers yet, or, they are still opting to fly well under the radar.

Augmedix – Augmedix claims to be the world’s first Google Glass start-up and their application focuses on improving the clinical documentation process. In January the company conducted a pilot with the California-based Dignity Health, who provided three family physicians with Google Glass and Augmedix’s physician documentation app. After four months the doctors reported a drop in the amount of time spent documenting from 33 percent of their day to nine percent and an increase in time spent directly engaging with patients from 35 to 70 percent of their day. Compared to some other vendors, the Augmedix application appears to be more narrowly focused.

ContextSurgery – The Context-aware software is geared to the operating room and includes a Surgical Dashboard that pushes relevant patient information to Glass-wearing providers. The HIPAA-compliant application also supports video-sharing. I assume that the company is still in the development stage as they are looking for additional betas to test their product.

CrowdOptic – ProTransport-1 recently announced it will deploy the CrowdOptic Google Glass broadcasting solution in its ambulances and mobile medical machines to broadcast real-time video of patients in transport.  UC San Francisco is also testing CrowdOptic software to enhance physician training through the use of live video streaming from Glass devices.

Pristine – Pristine offers the EyeSight product as a HIPAA-compliant, first-person audio/video streaming solution optimized for Google Glass. Currently their platform is in use at several facilities, including UC Irvine Medical School and Houston Methodist Hospital (to allow physicians to broadcast procedures to students or for continuing education purposes) and Rhode Island Hospital (for remote dermatology consults). The Chicago-based MedEx Ambulance service also recently acquired Pristine’s technology to allow Glass-wearing paramedics to transmit live video and audio from an ambulance to an ER doctor.

Remedy – Remedy has launched a pilot study with three Harvard hospitals in which Glass-wearing PAs will connect with doctors (usually at night), allowing the supervising physicians to “see” the patients. Remedy is targeting its application for use by residents, medical students, general practitioners, nurses, and PAs to extend the reach of specialists.

Wearable Intelligence – Physicians at Beth Israel Deaconess Medical Center are using devices from WI as a means of gaining hands free access to patient charts. The company also promotes a procedural checklist application and telehealth and video recording options for healthcare. In addition to the high-profile BIDMC, the multi-national oil services firm Schlumberger also uses WI’s Glass applications.

I’m impressed by the number of big-name health systems that are giving Google Glass a test drive. It’s also interesting to note the diversity of applications, from telehealth, education, remote consults, and EMR access. By the time HIMSS15 rolls around next April I am sure we’ll have a clearer idea of which vendors have figured out the formula for success.

And regardless how hot the market gets, I doubt I’ll be Glass-adorn any time soon.

Categories: News and Views , All

January 6,2014

GNUmed now supports the following workflow:

- patient calls in asking for documentation on his back pain

- staff activates patient

- staff adds from the document archive to the patient
  export area a few documents clearly related to episodes
  of back pain

- staff writes inbox message to provider assigned to patient

- provider logs in, activates patient from inbox message

- provider adds a few more documents into the export area

- provider screenshots part of the EMR into the export area

- provider includes a few files from disk into export area

- provider creates a letter from a template and
  stores the PDF in the export area

- provider notifies staff via inbox that documents
  are ready for mailing to patient

- staff activates patient from inbox message

- staff burns export area onto CD or DVD and
  mails to patient

- staff clears export area

Burning media requires both a mastering application
(like k3b) and an appropriate script gm-burn_doc
(like the attached) to be installed. Burning onto
some media the directory passed to the burn script
produces an ISO image like the attached.

GPG key ID E4071346 @
E167 67FD A291 2BEA 73BD  4537 78B9 A9F9 E407 1346

November 26,2013

Here it is

0.) do a full backup. Save it on some other media then your harddisk ! Do it,

1.) Install PG 9.3 ( I tried with 32bit but should not matter).

2.) Run the installer and select (English_UnitedStates) for locale (others
might work as well). Make sure it installs itself on port 5433 (or other but
never ! 5432).

3.) Make sure both PG 8.4 and PG 9.3 are running (e.g. via pgadmin3 from PG

4.) open a command shell (dos box) - "run as" administrator (!) in Win7

5.) type : RUNAS /USER:postgres "CMD.EXE"
- this will open another black box (command shell) for user postgres
- for the password use 'postgrespassword' (default)

6.) type: SET PATH=%PATH%;C:\Programme\PostgreSQL\9.3\bin;
- instead of Programme it might be Program Files on your computer

7.) type: cd c:\windows\temp
- changes directory to a writable temporary directory

8.) type: pg_dump -p 5432 -Fc -f gnumedv18.backup gnumed_v18

9.) type: pg_dumpall -p 5432 --globals-only > globals.sql

Important : Protect your PG 8.4 by shutting it down temporarly

10.) type in the first command shell : net stop postgresql-8.4
- check that is says : successfully stopped

11.) psql -p 5433 -f globals.sql
- this will restore roles in the new database (PG 9.3 on port 5433)

12.) pg_restore -p 5433 --dbname postgres --create gnumedv18.backup
- this will restore the database v18 into the PG 9.3 on port 5433

Congratulations. You are done. Now to check some things.

Here you could run the fingerprint script on both databases to check for an
identical hash


13.) Open gnumed.conf in c:\programme\gnumed-client\
For the profile GNUmed database on this machine ("TCP/IP": Windows/Linux/Mac)]
change port=5432 to 5433.

14. Run the GNUmed client and check that it is working. If it works (no wrong
schema hash detected) you should see all your patient and data.

15. If you have managed to see you patients and everything is there close
GNUmed client 1.3.x.

16.) in the first command shell type: net stop postgresql-9.3

17.) Go to c:\Ptogramme\PostgresPlus\8.4SS\data and open postgresql.conf. Find
port = 5432 and change it to port = 5433

18.) Go to c:\Programme\Postgresql\9.3\data and open postgresql. Find port =
5433 and change it to 5432. This effectively switches ports for PG 8.4 and 9.3
so PG 9.3 runs on the default port 5432.

19.)  Open gnumed.conf in c:\programme\gnumed-client\
For the profile GNUmed database on this machine ("TCP/IP": Windows/Linux/Mac)]
change port=5433 to 5432.

20.) Restart PG 9.3 with: net start postgresql-9.3.

21.) Open the GNUmed client and connect (to PG 9.3 on port 5432).

22.) Leave PG 8.4 in a shutdown state.

So far we have transferred database v18 from PG 8.4 to 9.3. No data from PG
8.4 is touched/lost.

23.) Now you are free to install gnumed-server v19 and gnumed -client 1.4.
Having installed gnumed-server v19 select 'database upgrade' (not boostrap
database) and it will upgrade your v18 database to a v19 database.

In case you experience problems you can always shut down PG 9.3, switch ports again, install client 1.3.x, start PG 8.4 (net start postgresql-8.4) and work with your old setup.

November 13,2013

The release notes prominently tell us that GNUmed 1.4.x requires at least PostgreSQL 9.1.

If you are running the Windows packages and have let GNUmed install PostgreSQL for you you are good to go since it comes with PostgreSQL 9.2 already.

If you are on Ubuntu or Debian Chances are your system still has PostgreSQL 8.x installed.

First check if you run any software that requires you to continue using PostgreSQL 8.x. If so you can install PG 9.1 side by side with it. If not let PG 9.1 replace PG 8.x

It usually works like this.

sudo apt-get install postgresql-9.1
sudo pg_upgradecluster 8.4 main

Then if you don't need PG 8.4 anymore you could

sudo pg_dropcluster --stop 8.4 main
sudo apt-get purge postgresql-8.4

Have fun.

March 6,2013


Healthcare executives are continuously evaluating the subject of RFID and RTLS in general.  Whether it is to maintain the hospitals competitive advantage, accomplish a differentiation in the market, improve compliance with requirements of (AORN, JCAHO, CDC) or improve asset utilization and operating efficiency.  As part of the evaluations there is that constant concern around a tangible and measurable ROI for these solutions that can come at a significant price.

When considering the areas that RTLS can affect within the hospital facilities as well as other patient care units, there are at least four significant points to highlight:

Disease surveillance: With hospitals dealing with different challenges around disease management and how to handle it.  RTLS technology can determine each and every staff member who could have potentially been in contact with a patient classified as highly contagious or with a specific condition.

Hand hygiene compliance: Many health systems are reporting hand hygiene compliance as part of safety and quality initiatives. Some use “look-out” staff to walk the halls and record all hand hygiene actives. However, with the introduction of RTLS hand hygiene protocol and compliance when clinical staff enter or use the dispensers can now be dynamically tracked and reported on. Currently several of the systems that are available today are also providing active alters to the clinicians whenever they enter a patient’s room and haven’t complied with the hand hygiene guidelines.

Locating equipment for maintenance and cleaning:

Having the ability to identify the location of equipment that is due for routine maintenance or cleaning is critical to ensuring the safety of patients. RTLS is capable of providing alerts on equipment to staff.

A recent case of a hospital spent two months on a benchmarking analysis and found that it took on average 22 minutes to find an infusion pump. After the implementation of RTLS, it took an average of two minutes to find a pump. This cuts down on lag time in care and can help ensure that clinicians can have the tools and equipment they need, when the patient needs it.

There are also other technologies and products which have been introduced and integrated into some of the current RTLS systems available.

EHR integration:

There are several RTLS systems that are integrated with Bed management systems as well as EHR products that are able to deliver patient order status, alerts within the application can also be given.  This has enabled nurses to take advantage of being in one screen and seeing a summary of updated patient related information.

Unified Communication systems:

Nurse calling systems have enabled nurses to communicate anywhere the device is implemented within the hospital facility, and to do so efficiently. These functionalities are starting to infiltrate the RTLS market and for some of the Unified Communication firms, it means that their structures can now provide a backbone for system integrators to simply integrate their functionality within their products.

In many of the recent implementations of RTLS products, hospital executives opted to deploy the solutions within one specific area to pilot the solutions.  Many of these smaller implementations succeed and allow the decision makers to evaluate and measure the impacts these solutions can have on their environment.  There are several steps that need to be taken into consideration when implementing asset tracking systems:

•             Define the overall goals and driving forces behind the initiative

•             Develop challenges and opportunities the RTLS solution will be able to provide

•             Identify the operational area that would yield to the highest impact with RTLS

•             Identify infrastructure requirements and technology of choice (WiFi based, RFID based, UC integration, interface capability requirements)

•             Define overall organizational risks associated with these solutions

•             Identify compliance requirements around standards of use


RFID is one facet of sensory data that is being considered by many health executives.  It is providing strong ROI for many of the adapters applying it to improve care and increase efficiency of equipment usage, as well as equipment maintenance and workflow improvement. While there are several different hardware options to choose from, and technologies ranging from Wi-Fi to IR/RF, this technology has been showing real value and savings that health care IT and supply chain executives alike can’t ignore.

February 21,2013


It was not long after mankind invented the wheel, carts came around. Throughout history people have been mounting wheels on boxes, now we have everything from golf carts, shopping carts, hand carts and my personal favorite, hotdog carts. So you might ask yourself, “What is so smart about a medical cart?”

Today’s medical carts have evolved to be more than just a storage box with wheels. Rubbermaid Medical Solutions, one of the largest manufacturers of medical carts, have created a cart that is specially designed to house computers, telemedicine, medical supply goods and to also offer medication dispensing. Currently the computers on the medical carts are used to provide access to CPOE, eMAR, and EHR applications.

With the technology trend of mobility quickly on the rise in healthcare, organizations might question the future viability of medical carts. However a recent HIMSS study showed that cart use, at the point of care, was on the rise from 26 percent in 2008 to 45 percent in 2011. The need for medical carts will continue to grow; as a result, cart manufacturers are looking for innovative ways to separate themselves from their competition. Medical carts are evolving from healthcare products to healthcare solutions. Instead of selling medical carts with web cameras, carts manufacturers are developing complete telemedicine solutions that offer remote appointments throughout the country, allowing specialist to broaden their availability with patients in need. Carts are even interfaced with eMAR systems that are able to increase patient safety; the evolution of the cart is rapidly changing the daily functions of the medical field.

Some of the capabilities for medical carts of the future will be to automatically detect their location within a healthcare facility. For example if a cart is improperly stored in a hallway for an extended period of time staff could be notified to relocate it in order to comply to the Joint Commission’s requirements. Real-time location information for the carts could allow them to automatically process tedious tasks commonly performed by healthcare staff. When a cart is rolled into a patient room it could automatically open the patient’s electronic chart or give a patient visit summary through signals exchanged between then entering cart and the logging device kept in the room and effectively updated.

Autonomous robots are now starting to be used in larger hospitals such as the TUG developed by Aethon. These robots increase efficiency and optimize staff time by allowing staff to focus on more mission critical items. Medical carts in the near future will become smart robotic devices able to automatically relocate themselves to where they are needed. This could be used for scheduled telemedicine visits, the next patient in the rounding queue or for automated medication dispensing to patients.

Innovation will continue in medical carts as the need for mobile workspaces increase. What was once considered a computer in a stick could be the groundwork for care automation in the future.

September 10,2012


This has been an eventful year for speech recognition companies. We are seeing an increased development of intelligence systems that can interact via voice. Siri was simply a re-introduction of digital assistants into the consumer market and since then, other mobile platforms have implemented similar capabilities.

In hospitals and physician’s practices the use of voice recognition products tend to be around the traditional speech-to-text dictation for SOAP (subjective, objective, assessment, plan) notes, and some basic voice commands to interact with EHR systems.  While there are several new initiatives that will involve speech recognition, natural language understanding and decision support tools are becoming the focus of many technology firms. These changes will begin a new era for speech engine companies in the health care market.

While there is clearly tremendous value in using voice solutions to assist during the capture of medical information, there are several other uses that health care organizations can benefit from. Consider a recent product by Nuance called “NINA”, short for Nuance Interactive Natural Assistant. This product consists of speech recognition technologies that are combined with voice biometrics and natural language processing (NLP) that helps the system understand the intent of its users and deliver what is being asked of them.

This app can provide a new way to access health care services without the complexity that comes with cumbersome phone trees, and website mazes. From a patient’s perspective, the use of these virtual assistants means improved patient satisfaction, as well as quick and easy access to important information.

Two areas we can see immediate value in are:

Customer service: Simpler is always better, and with NINA powered Apps, or Siri like products, patients can easily find what they are looking for.  Whether a patient is calling a payer to see if a procedure is covered under their plan, or contacting the hospital to inquire for information about the closest pediatric urgent care. These tools will provide a quick way to get access to the right information without having to navigate complex menus.

Accounting and PHR interaction: To truly see the potential of success for these solutions, we can consider some of the currently used cases that NUANCE has been exhibiting. In looking at it from a health care perspective, patients would have the ability to simply ask to schedule a visit without having to call. A patient also has the ability to call to refill their medication.

Nuance did address some of the security concerns by providing tools such as VocalPassword that will tackle authentication. This would help verify the identity of patients who are requesting services and giving commands. As more intelligence voice-driven systems mature, the areas to focus on will be operational costs, customer satisfaction, and data capture.

February 5,2013


[...] medical practice billing software  encourage [...]

August 21,2014


These days it’s pretty easy to build almost any kind of software you can imagine — what’s really hard, though, is figuring out what to build. As I work on complex software systems in government, medical devices, healthcare IT, and biomedical IT I find that tackling vague requirements is one of the most pervasive and difficult problems to solve. Even the most experienced developers have a hard time building something that has not been defined well for them; a disciplined software requirements engineering approach is necessary, especially in safety critical systems. One of my colleagues in France, Abder-Rahman Ali, is currently pursuing his Medical Image Analysis Ph.D. and is passionate about applying computer science to medical imaging to come up with algorithms and systems that aid in Computer Aided Diagnosis (CAD). He’s got some brilliant ideas, especially in the use of fuzzy logic and storytelling to elicit better requirements so that CAD may become a reality some day. I asked Abder-Rahman to share with us a series of blog posts about how to tackle the problem of vague requirements. The following is his first installment, focused on storytelling and how it can be used in requirements engineering: 

I remember when I was a child how my grandmother used to tell us those fictional and non-fictional stories. They still ring in my ears, even after those many years that have passed by. We used to just sit down, open our ears, stare our eyes, move around with our thoughts, and we don’t get out of such situation until the story ends. We used to make troubles sometimes, and to get us calm, we were just being called to hear that story, and the feelings above came to use again.

Phebe Cramer, in her book, Storytelling, Narrative, and the Thematic Apperception Test, mentions how storytelling has a long tradition in human history. She highlights what have been considered the significant means by which man told his story. Some of those for instance were the famous epic poems, the Iliad and the Odyssey from the ninth century B.C., the Aeneid from 20 B.C., the east Indian Mahabharata and Ramayana from the fourth century A.C., …etc. This is how history was transmitted from one generation to the other.

Storytelling Tips and Tales emphasizes that stories connect us to the past, and enlighten for us the future, lessons can be learned from stories, and information is transmitted transparently and smoothly through stories. Teachers in schools are even being encouraged to use storytelling at their classrooms. The books also believes that storytelling is an engaging process that is rewarding for both the teller and the listener. Listeners will like enter new worlds by just hearing the words of the teller. Schank and Abelson even see that psychological studies have revealed that human beings learn best from stories, in their Knowledge and Memory: The Real Story.

Having mentioned that, a requirements engineer may ask, why couldn’t we just then bring storytelling to our domain? Especially that in our work, there would be a teller and a listener. Well, could that really be?

Let us examine the relationships between story elements and a software requirement in order to answer that question.

In his book, Telling Stories: A Short Path to Writing Better Software Requirements, Ben Rinzler highlights such relationships as follows (some explanations for the points was also used from Using Storytelling to Record Requirements: Elements for an Effective Requirements Elicitation Approach):

  1. Conflict: This is the problem you want to solve in the requirements process. An example of that is the conflict that occurs between stakeholders needs and the FDA regulatory requirements for some medical device software.
  2. Theme:  This is the central concept underlying the solution. For requirements engineering, this could be a “requirement”, that is, the project goal.
  3. Setting: Knowing that the setting is the place and time of the story. In requirements engineering, this can be stated as the broader concept of the problem at hand, such as providing information about the technology environment, business, …etc.
  4. Plot: The plot of a story is its events that occur in a certain order, such that their outcome affects later once. In requirements engineering, this is the current and future systems’ series of actions.
  5. Character: This refers to any entity capable of action. In requirements engineering, this can for instance represent people, machines, and programs.
  6. Point of view: Having different points of view is important for providing a unified view that tries to provide a whole description of what is actually happening, and what everyone needs. This is like describing a medical device software process from the patient and physician points of view for instance.

So, yes, a relationship and an analogy exists between storytelling and software requirements.

In future posts in the series, Shahid and I will dig more deep on how storytelling could be employed in the requirements engineering process, and will also try to show how can fuzzy logic be embedded in the process to solve any issues that may be inherent in the storytelling method.

Meanwhile, drop us comments if there are specific areas of requirements engineering complex software systems that you’re especially interested in learning more about.

August 20,2014


Our vision of providing a series of packed one day events focused on practical, relevant, and actionable health IT advice were very well received in Houston, NYC, and Santa Monica earlier this year. Our next event is in Chicago and we’re going to continue to eschew canned PowerPoint decks which limit conversations and instead deliver on the implications of major trends and operationalizable advice about where to successfully apply IT in healthcare settings. As usual, the blind promotion of tech hype is going to be replaced with and actionable insights that can be put to immediate use. Based on some of the feedback we got from the 3 earlier events this year, it looks like we struck a chord:

“IMN have brought together a one-of-a-kind venue for the HealthIMPACT forum. It offers an opportunity to explore, in-depth, the intersection of emerging models of cloud computing with solving some of our toughest problems in health information technology. It’s a great opportunity to meet national thought leaders and explore these issues at depth in an intimate setting. ” - Keith Toussaint, Executive Director, Business Development, Global Business SolutionsMAYO CLINIC

“You had a pretty engaged group yesterday. I would think you regard the meeting as successful; it was in a beautiful venue. ” - David S. Mendelson, MD, FACR, Co-Chair Integrating the Healthcare Enterprise, Professor of Radiology, Director of Radiology Information Systems Pulmonary Radiology, Senior Associate, Clinical InformaticsMOUNT SINAI MEDICAL CENTER

“[The open format] allows for valuable exchange between participants. The forum consists of important topics and fluid discussions going where the audience wants to take it.” – George Conklin, Senior Vice President and CIOChristus Health

“HealthIMPACT seemed more focused with only high quality contributors and content. HealthIMPACT was collaborative with fewer ‘talking heads’ and more open and honest dialog. I truly felt that it was a more intimate environment for sharing.” – Zachery Jiwa, Innovation FellowUS Department of Health and Human Services

I’m often asked why, as a health IT blogger, I wanted to lead HealthIMPACT. Here’s a three minute video overview that explains my thinking:

Based on the feedback from the Houston, NYC, and Santa Monica events and what we’ve heard from our surveys, below are some of the topics we plan to cover in Chicago on September 8th at HealthIMPACT Midwest.

  • Reckoning with the Challenges of Meaningful Use Stage 2
  • Fear and loathing as well as excitement around new risk-based collaborative payment systems and value based reimbursement
  • Cutting through the Health IT Hype Cycle – The Top Five Things That Matter When You are Running a Health System
  • Using Mobile Applications to Align Caregiver Behavior to Enterprise Initiatives While Improving Patient Satisfaction and Outcomes
  • Doing More with Less – Clinical and Financial Integration Required to Deliver True Population Based Health Management for a Value-Based Reimbursement Environment
  • Interoperability and Coordination of Care across Multiple Providers – Realizing the Value of Health Information Exchange
  • Working With Tech Providers to Build and Implement Technology That Works for Your Physicians, Nurses, and Patients
  • A Look to the Future of Clinical Decision Support and Analytics
  • Using Advanced Analytics to Improve the Patient Experience for your Community
  • Creating the IT Integration Playbook for Success During Mergers and Expansions
  • What You Can Do to Protect Your Organization as You Become More Dependent on Cloud Based Services
  • Innovation Shark Tank – The Questions You Need to Ask and the Questions Vendors Need to be Ready For

All of the prepared agenda items above will be delivered in a unique and novel way so that the audience can drive the direction of the conversation. At HealthIMPACT we ask our audience to keep us honest, and they do. Some of the other topics that will be woven throughout the day include:

Data integration and system interoperability

  • Information exchange between hospital and outside groups/providers
  • Mobile interoperability of Patient Data
  • Interoperability strategies to ensure exchange of quality information
  • HIE Connectivity, Direct Trust Testing/Connectivity
  • Improved communication between providers

Population Health and Patient Engagement

  • How will involvement of patients in their own care change the way healthcare is practiced? Will it really?
  • What efforts are being made to reach out to the average patient in the population so they can access and use the health care system the same way that the average person is able to use the banking or retail system?

Data Governance

  • Ensuring data accuracy
  • Control data output to ensure it is of highest quality and provides consistent outcomes.
  • Data governance, measure burden, data analysis
  • Strategies for accurate and reliable data entry
  • Ensuring the quality of information within your EMR
  • Use of computerized assisted clinical documentation or coding to improve clinical outcomes
  • CAC, Computer Assisted Physician Documentation (CAPD)
  • Master Data Management
  • Reconciliation of data between systems

Meaningful Use

  • Assuring on-time and on-budget completion of projects (principally MU2), in the face of reduced reimbursement and personnel resources.
  • Implementation of MU 2
  • Meeting MU2 and CMS rules w/minimal impact on physician workflow/productivity
  • Transition of Care (TOC) measure and use of CCDA & DIRECT Messaging
  • Developing solutions that will satisfy conflicting requirements between CMS sections, without requiring staff to do multiplicative documentation.
  • Effective Clinical Integration Ideas EHR (Epic Implementation)
  • Epic implementation
  • Interoperability legacy systems and modern systems
  • Keeping track of rapid changes in software in the electronic health record
  • Keeping track of changes from CMS
  • Staying current of IT information that comes so fast
  • Meaningful Use Audits
  • Implementing electronic medical record
  • Successfully attestation for Stage 2 Phase 1 MU
  • Maintaining metrics in the face of ever changing regulatory requirements
  • Transition of the traditional quality core measures to the electronic clinical quality measures
  • Managing changes in workflows as new components in the EHR are implemented to meet meaningful use requirements

Clinical Informatics

  • Use of analytics/data to coordinate care and cut costs
  • Developing Heath Care Data and Analytics division
  • Knowledge of successful strategies to move forward clinical informatics agenda
  • Population Heath and Data Mining
  • Not seeing nursing informatics (N I) working in our healthcare facilities
  • Seeing NI as a leaders in the field.
  • Job availability for NI
  • Ways in which nursing informatics is impacting healthcare
  • The integration of Nursing informatics as a part of IT in healthcare
  • Focus on nursing informatics and their role in healthcare
  • cost big data interoperability

Clinical Decision Support

  • Enabling more robust clinical decision support
  • Exploring, and successfully implementing alternate delivery methods of care


  • How to get the most out of mobile platforms.
  • Role of mobile devices in Health IT.
  • Telehealth
  • Clinical solutions and patient engagement solutions
  • How to be successful with cloud strategies

Cost & Resources

  • Ensuring that using IT in care delivery actually helps in reducing cost of healthcare Cutting cost of the contracted services
  • Supporting the education efforts of various departments, without having to assume responsibility for conducting the actual education
  • Prioritizing to corporate strategic direction.
  • Workflow of IT operations area – more efficient
  • How to evaluate new technoloty
  • global sense of what the most useful cutting edge technologies are
  • Resources Money changes in government regulations
  • Project management C-suite expectations Talent acquisition
  • Money to implement, train, maintain. Trained technical people. Affordable bandwidth.
  • Funding; dealing with increasing integration requirements; need for speed in an increasing complicated environment.
  • Budgets Finding qualified staff to fill positions GRC culture change to make the business more responsible for their applications
  • Change management in general


  • What start-up technologies are larger institutions potentially looking at?
  • What apps should patients be “prescribed”?
  • Trends, direction in technologies for new technologies like wearable technology etc.


  • System implementation Security
  • Authentication, electronic signature
  • Medical & Personal Device Security
  • Security and Privacy Mobility

August 17,2014


I’ve been looking at hospital supply chain automation and the IT surrounding it for a number of years now. Starting with Cardinal Health but then moving on to help a number of other vendors in the space, I’ve felt that there’s not been enough next-generation tech being applied to the low margin, high volume business of hospital supply management. Hospitals often spend tens of millions of dollars on EHRs and other IT systems that have little direct cost reduction capability but they ignore, often at their peril, supply management systems that can save immediate dollars. There seems to be a light at the end of the tunnel, though. Earlier this year I joined the board of Hybrent, led by founder and supply chain expert Harold Richards, because I instantly saw the value of what they were doing. While Hybrent is a startup funded by a couple of friends that I know have been successful in the past, I joined primarily because of Harold’s 21 years testing, applying, measuring and implementing supply chain strategies that have driven well over $50 million in costs out of the supply chain units where he’s served. While supply chain automation is often seen as an administrative activity, I’ve seen first hand that it’s actually directly tied to increase in patient & nursing satisfaction. I asked Harold to tell us a little about why supply chain automation is so important and here’s what he had to say:

Does Your Hospital Supply Chain Have Traits Of An Ant Farm?

You may have had an ant farm as a child and marveled at the cooperative efforts and precision of the ants as they went about their daily activities. Thanks to the panes of glass, you could see into the inner workings of the ant society at all levels and depths.

That same level of effort went into the anthill in the backyard – maybe even more due to the lack of protection. Yet it went unnoticed because it was underground. You only noticed problems when they affected ants that you could see at the top of the anthill.

So it is with the hospital supply chain, full of hard working individuals who run into daily challenges just as ants do. Both rely on excellent systems of communication to get things accomplished. However, ants do not have to deal with bureaucracy, integrating of mismatched systems, missing supplies and other time-wasting system failures (at least not as far as we can tell).

Front-line healthcare workers do spend precious time dealing with these problems, resulting in inefficiencies, higher costs, and potential poor patient outcomes. Spending 20% of your nurses’ time on supply scavenger hunts does not help anyone – certainly not the nurses.

Not only does this cause inefficient use of time, it causes inventory chaos – incorrect counts, hoarding supplies, missing orders and the like – that can snowball throughout your supply chain system. You have stressed and unhappy ants, so to speak.

These misfires cause turmoil within the ant farm and can lead to accidents like sentinel events.  Looking at the bigger picture within healthcare, we are expected to do more with less. In my opinion this is a recipe for disaster.

Today, droves of patients are flocking to the ER’s like never before seeking treatment. As a result, emergency rooms all over the country are filled beyond capacity levels with less staff, more workload and higher expectations. According to USA TODAY, some hospitals are seeing 12% spikes.  Purely from a metrics perspective this may not seem like much, but could result to patients dying while waiting for care.

With this increase in volume there now becomes a higher risk and demand for medical supplies & enhancement in supply chain efficiencies. The reality we live in is this; incorporating anything less than the traits of an ant farm will cause major mishaps in form of patients dying.  It’s a sentinel event just waiting to happen.

Just imagine something as minor as clinical caregivers not having instant access to trauma, respiratory, and EMS supplies within a already busy emergency department while a patient is being triaged with chest pains. Quite a frightening forecast when you think about it.  As they say, future behavior is predicated upon past behavior.  The future outcomes of your patients weigh heavily on your actions.

As a hospital executive, your view may be that of the backyard anthill – you have surface information that gives you superficial knowledge, but without the overall view you need to fully anticipate or fix problems. Meanwhile, your care providers may be dealing with supply chain systems that hamper effective communication instead of enhancing it.

If you’re not doing these three things your patients are at risk and your hospital is losing millions of dollars in supply chain management:

  1. You must setup a transparent assignable communication system for the front-line staff – A system allowing your “ants” to effectively communicate. With rules and filters that you define, user-friendly menus simplify the ordering process for your nurses and give real–time feedback that propagates through your system via real-time push-notifications and alerts. It’s imperative that everyone from nurses to supply chain personnel to trading partners works off the same set of information.
  2. Compiles data, giving you and your staff immediate access to as much data as you need, based on your preferred settings. This gives you the “panes of glass,” if you will, to see into the complex workings of your system at any point in time. It’s equally important to have this data embedded within daily workflows to effectively make better business decisions.
  3. Be accountable for setting up the rules and analytics that are important to your organization. Sense the need of urgency to prevent as well as fix problems. You can either process the output of the visibility system through a separate analytical engine to get the insight you need, or integrate the two along with any other useful support system.

The key is to get you the information and facts you need to make decisions when you need it, and not to overwhelm yourself with frivolous or useless information. If you can’t see the overall picture, and can’t interpret it, you can’t fix it. That is true at both the executive and care-provider level. Do you really know what’s going on in your “anthill” today?

Ants are models of efficiency, and with a proper Supply Chain Visibility System, your front-line care providers will be as well. They will be thrilled with the ability to streamline their time and prevent supply chain snafus. They will probably forgive you for any ant analogies you want to draw – although you’ll have to gauge that for yourself.

Editor’s note: If you’re wondering what’s going on in your anthill, e-mail Harold to get a free 30 minute Supply Chain “Clarity Session” consultation, which consists of answering a few questions and getting some pretty impressive actionable intelligence in a short thirty-minute call.


March 12,2010

This blog is now located at You will be automatically redirected in 30 seconds, or you may click here. For feed subscribers, please update your feed subscriptions to Rod

March 3,2010

I've just heard about the Information Technology and Communications in Health (ITCH) which will be held February 24 - 27, 2011, Inn at Laurel Point, Victoria, BC Canada.I'd not heard of this conference before but the current call for papers looks interesting.Health Informatics: International Perspectives is the working theme for the 2011 international conference. Health informatics is now a Rod
The report of the Prime Minister’s Commission on the Future of Nursing and Midwifery in England sets out the way forward for the future of the professions which was published yesterday, calls for the establishment of a "high-level group to determine how to build nursing and midwifery capacity to understand and influence the development and use of new technologies. It must consider how pre- and Rod

June 9,2013


“Large collections of electronic patient records have long provided abundant, but under-explored information on the real-world use of medicines. But when used properly these records can provide longitudinal observational data which is perfect for data mining,” Duan said. “Although such records are maintained for patient administration, they could provide a broad range of clinical information for data analysis. A growing interest has been drug safety.”

In this paper, the researchers proposed two novel algorithms—a likelihood ratio model and a Bayesian network model—for adverse drug effect discovery. Although the performance of these two algorithms is comparable to the state-of-the-art algorithm, Bayesian confidence propagation neural network, by combining three works, the researchers say one can get better, more diverse results.


I saw this a few weeks ago, and while I haven't had the time to delve deep into the details of this particular advance, it did at least give me more reason for hope with respect to the big picture of which it is a part.

It brought to mind the controversy over Vioxx starting a dozen or so years ago, documented in a 2004 article in the Cleveland Clinic Journal of Medicine. Vioxx, released in 1999, was a godsend to patients suffering from rheumatoid arthritic pain, but a longitudinal study published in 2000 unexpectedly showed a higher incidence of myocardial infarctions among Vioxx users compared with the former standard-of-care drug, naproxen. Merck, the patent holder, responded that the difference was due to a "protective effect" it attributed to naproxen rather than a causative adverse effect of Vioxx.

One of the sources of empirical evidence that eventually discredited Merck's defense of Vioxx's safety was a pioneering data mining epidemiological study conducted by Graham et al. using the live electronic medical records of 1.4 million Kaiser Permanente of California patients. Their findings were presented first in a poster in 2004 and then in the Lancet in 2005. Two or three other contemporaneous epidemiological studies of smaller non-overlapping populations showed similar results. A rigorous 18-month prospective study of the efficacy of Vioxx's generic form in relieving colon polyps showed an "unanticipated" significant increase in heart attacks among study participants.

Merck's withdrawal of Vioxx was an early victory for Big Data, though it did not win the battle alone. What the controversy did do was demonstrate the power of data mining in live electronic medical records. Graham and his colleagues were able to retrospectively construct what was effectively a clinical trial based on over 2 million patient-years of data. The fact that EMR records are not as rigorously accurate as clinical trial data capture was rendered moot by the huge volume of data analyzed.

Today, the value of Big Data in epidemiology is unquestioned, and the current focus is on developing better analytics and in parallel addressing concerns about patient privacy. The HITECH Act and Obamacare are increasing the rate of electronic biomedical data capture, and improving the utility of such data by requiring the adoption of standardized data structures and controlled vocabularies.

We are witnessing the dawning of an era, and hopefully the start of the transformation of our broken healthcare system into a learning organization.


Source: FutureHIT

June 7,2013


I believe if we reduce the time between intention and action, it causes a major change in what you can do, period. When you actually get it down to two seconds, it’s a different way of thinking, and that’s powerful. And so I believe, and this is what a lot of people believe in academia right now, that these on-body devices are really the next revolution in computing.


I am convinced that wearable devices, in particular heads-up devices of which Google Glass is an example, will be playing a major role in medical practice in the not-too-distant future. The above quote from Thad Starner describes the leverage point such devices will exploit: the gap that now exists between deciding to make use of a device and being able to carry out the intended action.

Right now it takes me between 15 and 30 seconds to get my iPhone out and do something useful with it. Even in its current primitive form, Google Glass can do at least some of the most common tasks for which I get out my iPhone in under five seconds, such as taking a snapshot or doing a Web search.

Closing the gap between intention and action will open up potential computing modalities that do not currently exist, entirely novel use case scenarios that are difficult even to envision before a critical mass of early adopter experience is achieved.

The Technology Review interview from which I extracted the quote raises some of the potential issues wearable tech needs to address, but the value proposition driving adoption will soon be truly compelling.

I'm adding some drill-down links below.

Source: FutureHIT

Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH.


One bit of good news about the Patient Centered Medical Home (PCMH) model: here is a study showing that in spite of considerable challenges to PCMH implementation, the transformations it embodies can be and are being implemented even in small primary care practices serving disadvantaged populations.

Source: FutureHIT

August 9,2014

The HIFA Voices database will bring together the experiential knowledge of HIFA members: more than 12,000 professionals from over 2500 organisations in 170 countries, ranging from senior executives at the World Health Organization in Geneva to community health workers in rural Gambia. Our common vision is a world where every person and every health professional has access to the information they need to protect their own health and the health of those for whom they are responsible. HIFA Voices will be launched on 12 August 2014.

HIFA Voices harnesses the practical expertise of providers and users of healthcare information, together with relevant health information sciences literature. This helps us to understand the healthcare information needs of different users in different contexts and how these needs can be more effectively addressed. Further information about HIFA Voices.

Read the blog about HIFA Voices on the ElsevierConnect website, and the press release from mPowering Frontline Health Workers and Intel Corporation.

We are currently seeking further financial and technical support to enable us to develop HIFA Voices through 2015 and beyond. Please contact us for details.

My source: HIFA2015 list.
Categories: News and Views , All

July 9,2014

Dear ERCIM News Reader,

ERCIM News No. 98 has just been published at:

Special Theme: "Smart Cities"

featuring a keynote by Eberhard van der Laan, Mayor of Amsterdam

Guest editors:
- Ioannis Askoxylakis, ICS-FORTH, Greece
- Theo Tryfonas, Faculty of Engineering, University of Bristol, UK

This issue is also available for download as:

Next issue: No. 99, October 2014 - Special Theme: "Quality Software"
(see Call at

Thank you for your interest in ERCIM News.
Feel free to forward this message to others who might be interested.

Best regards,
Peter Kunz
ERCIM News central editor

Urban Civics - Democratizing Urban Data for Healthy Smart Cities
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‘U-Sense’, A Cooperative Sensing System for Monitoring Air Quality in Urban Areas 
is published quarterly by ERCIM, the European Research Consortium for Informatics and Mathematics.
The printed edition will reach about 6000 readers.
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Categories: News and Views , All

July 5,2014


In learning we often look in turn for role models, exemplars then even some comparator or examples against which to compare and contrast to understand the context and our own knowledge, skills and potential.

In health and social care information systems it's useful for me to look at what is available in Drupal. A recent find is Care2X with a demo available. There are numerous plans to take these systems further:

 Care3g is seeking funding.

There is also Project Mtuha.

There's a post by Tim Schofield - Helping African hospitals with open source software that describes how the enterprise resource planning system KwaMoja @KwaMoja is being used to provide administration systems for hospitals in Africa.

Even though not on the same scale as commercial hospital systems in the USA and EU ... these are significant software projects compared with my purposes which are educational.

Care2X presentation
Categories: News and Views , All

October 14,2012


Image of clipboard with checklist


Twitter, like the Internet in general, has become a vast source of and resource for health care information. As with other tools on the Internet it also has the potential for misinformation to be distributed. In some cases this is done by accident by those with the best intentions. In other cases it is done on purpose such as when companies promote their products or services while using false accounts they created.

In order to help determine the credibility of tweets containing health-related content I suggest the using the following checklist (adapted from Rains & Karmikel, 2009):

  1. Author: Does the tweet contain a first and last name? Can this name be verified as being a real person by searching it on the Internet?
  1. Date: When was the tweet sent? If it is a re-tweet when was the original tweet sent?
  1. Reference: Does the tweet reference a source? Is this source reliable?
  1. Statistics: Does the tweet make claims of effectiveness of a product or service using statistics? Are the statistics used properly?
  1. Personal story or testimonials: Does the tweet contain claims from an individual who has used or conducted research on the product or service? Is this individual credible?
  1. Quotations: Does the tweet quote or cite another source of information (e.g. a link) that can be checked? Is this source credible?

Ultimately it is up to the individual to determine how to use health information they find on Twitter or other Internet sources. For patients anecdotal or experiential information shared by others with the same illness may be considered very credible. Others conducting research may find this a less valuable information source. Conversely a researcher may only be looking for tweets that contain reference to peer-reviewed journal articles whereas patients and their caregivers may have little or no interest in this type of resource.


Rains, S. A., & Karmike, C. D. (2009). Health information-seeking and perceptions of website credibility: Examining Web-use orientation, message characteristics, and structural features of websites. Computers in Human Behavior, 25(2), 544-553.






June 26,2012


The altmetric movement is intended to develop new measures of production and contribution in academia. The following article provides a primer for research scholars on what metrics they should consider collecting when participating in various forms of social media.



If you participate on Twitter you should be keeping track of the number of tweets you send, how many times your tweets are replied to, re-tweeted by other users and how many @mentions (tweets that include your Twitter handle) you obtain. ThinkUp is an open source application that allows you to track these metrics as well as other social media tools such as Facebook and Google +. Please read my extensive review about this tool. This service is free.

You should register with a domain shortening service such as, which will provide you with an API key that you can enter into applications you use to share links. This will provide a means to keep track of your click-through statistics in one location. records how many times a link you created was clicked on, the referrer and location of the user. Consider registering your own domain name and using it to shorten your tweets as a means of branding. In addition, you can use your custom link on electronic copies of your CV or at your own web site. This will inform you when your links have been clicked on. You should also consider using to create links used at your web site, providing you with feedback on which are used the most often. For example, all of the links in this article were created using my custom domain. In addition, you can tweet a link to any research study you publish to publicize as well as keep track of how many clicks are obtained. is a free service.


Another tool to measure your tweets is TweetReach. This service allows you to track the reach of your tweets by Twitter handle or tweet. It provides output in formats that can be saved for use elsewhere (Excel, PDF or the option to print or save your output by link). To use these latter features you must sign up for an account but the service is free.


Buffer is a tool that allows you to schedule your tweets in advance. You can also connect Buffer to your account so links used can be included in your overall analytics. Although Buffer provides its own measures on click-through counts this can contradict what appears in This service is free but also has paid upgrade options available that provide more detailed analytics.

Web presence

Google Scholar Citation Profile

You can set up a profile with Google Scholar based on your publication record. The metrics provided by this service include a citation count, h-index and i10-index. When someone searches your name using Google Scholar your profile will appear at the top before any of the citations. This provides a quick way to separate your articles from someone else who has the same name as you.

Google Feedburner for RSS feeds

If you maintain your own web site and use RSS feeds to announce new postings you can also collect statistics on how many times your article is clicked on. Feedburner, recently acquired by Google provides one way to measure this. You enter your RSS feed ULR and a report is generate, which can be saved in CVS format.

Journal article download statistics

Many journals provide statistics on the number of downloads of articles. Keep track of those associated with your publication by visiting the site. For example, BioMed Central (BMC) maintains an access count of the last 30 days, one year and all time for each of your publications.


Other means of contributing to the knowledge base in your field include participating on web-based forums or web sites such as Quora. Quora provides threaded discussions on topics and allows participants to both generate and respond to the question. Other users vote on your responses and points are accrued. If you want another user to answer your question you must “spend” some of your points. Providing a link to your public profile on Quora on your CV will demonstrate another form of contribution to your field. is a free service that curates content and renders it in a web-based format. The focus of my is the use of technology in Canadian Healthcare. I have also created a page that appears at my web site. Metrics on the number of times your paper has been shared via Facebook, Twitter, Google + and Linked are available. This service is free.


Twylah is similar to in that it takes content and displays it in a newspaper format except it uses your Twitter feed. There is an option to create a personalized page. I use I also have a Twylah widget at my web site that shows my trending tweets in a condensed magazine layout. It appears in the side bar. This free service does not yet provide metrics but can help increase your tweet reach. If you create a custom link for your Twylah page you can keep track of how many people visit it.

Analytics for your web site

Log file analysis

If you maintain your own web site you can use a variety of tools to capture and analyze its use. One of the most popular applications is Google Analytics. If you are using a content management system such as WordPress there are many plug-ins that will add the code to the pages at your site and produce reports. WordPress also provides a built-in analytic available through its dashboard.

If you have access to the raw log files you could use a shareware log file program or the open source tool Piwik. These tools will provide summaries about what pages of your site are visited most frequently, what countries the visitors come from, how long visitors remain at your site and what search terms are used to reach your site.


All of this information should be included in the annual report you prepare for your department and your tenure application. This will increase awareness of altmetrics and improve our ability to have these efforts “count” as contributions in your field.

June 24,2012

  1. The following provides a timeline of articles that appeared in newspapers and blogs from January 2011 to present. The articles demonstrate a progress from patient engagement in online communities to those that include reference to increasing provider involvement.
  2. January 5th, 2011
  3. February 3rd, 2011
  4. February 22nd, 2011
  5. March 23rd, 2011
  6. April 2nd, 2011
  7. April 25th, 2011
  8. May 14th, 2011

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